While the Disease Management Care Blog has previously opined on the option of a Federally funded public payor multiple times, Uwe Reinhardt has jumped into the debate over at the New York Times’ Economix blog. Here's a short version for you:

While Americans give government-run health insurance high marks, special interests are sharpening their battle axes in opposition to the idea. Private insurers fear having to compete against lower prices and hidden subsidies. Health care providers fear having to deal with an all powerful payor. Both private insurers and health care providers will fight back by stoking fears of ‘rationing.’ Professor Reinhardt confides he has a solution that will bring peace and prosperity across the land. Unfortunately, it is a ‘secret until a future post.’

It may also be wrong. The DMCB thinks that may be the case because Professor Reinhardt’s assumptions about the providers and insurers are mistaken:

According to this survey by Deloitte, the majority of persons with any health insurance are satisfied with their current plan. There is little evidence that persons with employer based insurance would welcome a government program or vice versa. Rather, persons who cannot afford health insurance would probably welcome any insurance, public or private.

The fears of the private insurers have less to do with being able to command a matching low price from the providers in their networks (insurers generally negotiate payments with providers on a percent of the standard Medicare fee schedule anyway) or with hidden subsidies (Medicare’s administrative costs are low because of opaque regulations that effectively transfer that cost to the provider), but with the government's legacy of cost shifting.

Providers in many locales argue they are already dealing with health insurer monopsonies (for example, here and here). What’s one more?

Just because consumers fear rationing doesn’t mean that their fears are unjustified. While it is true that the lack of insurance is an effective 'shadow' form of rationing, Massachusetts’ willingness to put health insurance ahead of health care reform may well lead to showing how having insurance may lead to explicit rationing.

Last but not least, Professor Reinhardt ignores the role of population-based care programs. Will a Federally funded public payor provide disease management options for patients that need it? The DMCB and the CBO think that’s a good idea. Will private insurers use care management programs to compete against a public plan that neglects that option? The DMCB thinks they should. Will the public plan work with provider-based patient centered medical homes? The DMCB thinks that’s an important option. Can the leverage of other care providers such as nurses that coach patients to be better stewards of their health reduce the likelihood of having to ration health care? The DMCB says the answer is yes at many levels.

In the meantime, the DMCB likes this idea from Kevin MD courtesy of Maggie Mahar’s Health Beat Blog: we’ll know how well a public payor option is working by the percent of physicians that accept it. When the DMCB finally gets to see Professor Reinhardt’s secret, it will use the likelihood of physician acceptance as a gauge of its likely success. It will also look critically at how well it would accommodate intelligently designed care management programs.